Healthcare Provider Details

I. General information

NPI: 1215857628
Provider Name (Legal Business Name): SAMUEL MARTIN KIMBLEY CRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 MEMPHIS ST
FORT SMITH AR
72901-7923
US

IV. Provider business mailing address

1601 MEMPHIS ST
FORT SMITH AR
72901-7923
US

V. Phone/Fax

Practice location:
  • Phone: 479-414-5605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: